Difficult Airway Management Procedure Note

(Use this template only for difficult airway events that were anticipated or encountered, involved multiple attempts or escalation, required rescue oxygenation or invasive access, or warrant explicit guidance for future teams. Do not use for routine straightforward intubations.)

Date/Time Started: [Date and time airway management began]

Date/Time Airway Secured: [Date and time final airway secured, or "Not secured"]

Location: [OR / ICU / ED / Ward / Prehospital / Other]

Urgency: [Elective / Urgent / Emergent / Crash]

Airway Context: [Anticipated difficult airway / Unanticipated difficult airway / Extubation difficulty / Airway exchange / Other]

Primary Indication: [Respiratory failure / Airway protection / Anesthesia / Airway obstruction / Aspiration risk / Other]

Patient Positioning: [Supine / Ramped / Sitting / Cervical spine precautions / Other]

Personnel: [Primary operator], [Assistant(s)], [Respiratory therapy], [Surgical airway backup: present / on-call / not available]

Time-Out: [Performed at time / Not performed due to reason]

Airway Risk Assessment

Pertinent History: [Prior difficult airway details including what worked and what failed; relevant anatomy or pathology; physiologic risk factors for rapid desaturation; aspiration risk factors] (Only include items explicitly known. Document unknowns as "Unknown." Do not infer.)

• Mouth opening: [Measured value / Adequate / Limited / Unable to assess due to reason]
• Mallampati: [I / II / III / IV / Not assessed / Unable to assess due to reason]
• Thyromental distance: [Measured value / Adequate / Reduced / Not assessed / Unable to assess due to reason]
• Neck mobility: [Full / Limited / Immobilized / Not assessed / Unable to assess due to reason]
• Dentition: [Intact / Loose teeth / Edentulous / Dental prosthetics / Not assessed]
• Facial hair/trauma/swelling: [Present with details / Absent / Not assessed]
• Baseline SpO2 and O2 device: [SpO2 percentage on room air / nasal cannula / face mask / NRB / NIV / HFNC / Unknown]

• Difficult mask ventilation: [Yes / No / Unknown] (Specify anticipated vs. encountered if applicable)
• Difficult supraglottic ventilation: [Yes / No / Unknown]
• Difficult laryngoscopy: [Yes / No / Unknown]
• Difficult intubation: [Yes / No / Unknown]
• Failed intubation: [Yes / No / Unknown]
• CICO event: [Yes / No / Unknown]
• Front-of-neck access required: [Yes / No / Unknown]

Airway Summary: [One to two sentences describing the dominant problem and the successful solution] (Be specific about what was difficult and what improved it.)

Airway Strategy (Plan A/B/C/D)

Approach: [Awake / Post-induction] — Rationale: [Reason for approach selection]

Plan A (Primary): [Device and technique, blade type, adjuncts, intended ETT size, optimization maneuvers]

Plan B (Rescue/Alternative): [Backup device or technique, supraglottic device, alternate laryngoscope, flexible scope; criteria to switch]

Plan C (Restore Ventilation/Wake): [Criteria to stop attempts, plan to restore spontaneous breathing or abort]

Plan D (Emergency Invasive): [Front-of-neck access approach, who would perform, equipment status and location]

Help and Resources: Additional help summoned: [Yes / No]; Surgical backup: [Notified and present / Notified / Not notified]; Stop-and-think pause: [Performed at time / Not performed]

Revised Strategy: [If difficulty was unanticipated, document initial plan and revised strategy with triggers for change] (Omit if difficulty was anticipated and plan unchanged.)

Oxygenation Strategy

• Preoxygenation: [Method, duration, and quality; or unable due to reason]
• Apneic oxygenation: [Used with device / Not used / Not available]
• Between-attempt ventilation: [Two-person mask / Oral airway / Nasal airway / SAD type and size / None] (Include effectiveness.)
• Desaturation episodes: [Yes / No] (If yes: nadir SpO2, precipitating factors, intervention that restored oxygenation.)
• Capnography during mask/SAD: [Confirmed effective ventilation / Not confirmed / Not used]

Attempt Log

(An attempt is defined as one insertion of a laryngoscope or airway device with intent to intubate or ventilate, ending when the device is removed or a different operator/device is used. Duplicate the following block for each attempt.)

Attempt [Number]: [Success / Failure / Aborted]

• Timestamp or sequence: [Time or order]
• Operator: [Name and role]
• Device/Technique: [VL with blade type and size / DL with blade type and size / Flexible scope / Intubating SAD / Other]
• Adjuncts: [Bougie / Stylet / External laryngeal manipulation / Suction / Cricoid pressure applied or released / None]
• Laryngoscopic view: [Cormack-Lehane grade / POGO percentage / Not documented]
• ETT details if placed: [Size, type, route, depth at teeth or lips, cuff status]
• Outcome: [Success / Failure / Aborted] — If unsuccessful: [Reason such as glottis not visualized, unable to pass tube, hypoxemia forced stop]
• Lowest SpO2 during attempt: [Percentage]; Hemodynamic events: [Description or none]
• Complications during attempt: [Dental trauma / Bleeding / Aspiration concern / Laryngospasm / Bronchospasm / None]

Key Transitions and Escalation

• Declaration of failed intubation or difficult ventilation: [Yes at time / No]
• Escalation triggers: [Trigger for each plan change, e.g., A→B, B→C, C→D]
• Decision to wake/abort vs proceed: [Decision and rationale]

Rescue Supraglottic Device

(Include only if SAD used for rescue oxygenation.)

• Device type and size: [Type and size]
• Insertion attempts: [Number and details]
• Oxygenation/ventilation adequacy: [Adequate / Inadequate] (Include capnography confirmation if available.)

Front-of-Neck Access / Surgical Airway

(Include only if performed.)

• Technique: [Cricothyrotomy / Tracheostomy / Needle-cannula with jet ventilation / Other]
• Operator: [Name and role]
• Confirmation method(s): [Capnography / Bronchoscopy / Ultrasound / Chest rise]
• Complications: [Description or none]

Confirmation and Final Airway Status

• Confirmation method(s): [End-tidal CO2/capnography / Bilateral breath sounds / Chest rise / Ultrasound / Bronchoscopy] (If any uncertainty existed, document how resolved.)
• Final airway status: [Secured / Not secured]
• Final device: [ETT / SAD / Tracheostomy / None] — Size and type: [Details]
• ETT position: Depth: [cm at teeth or lips]; Cuff: [Inflated / Deflated]; Secured with: [Tape / Commercial device / Sutures]
• Immediate post-placement: [Sedation plan, ventilator initiated, chest imaging ordered if applicable]

Airway-Relevant Medications

(List only medications directly relevant to airway management.)

• Topical airway anesthesia: [Agent, concentration, volume, sites, time]
• Induction agent(s): [Drug, dose, route, time]
• Neuromuscular blockade: [Drug, dose, route, time; include reversal if given]
• Hemodynamic support: [Vasopressors or antihypertensives for airway-related instability: drug, dose, route, time]

Complications and Post-Event Evaluation

(Document with explicit negatives for key items. If patient cannot be assessed, state reason.)

• Hypoxemia: [Yes / No] — If yes: nadir SpO2 [percentage], management [intervention]
• Hypotension or bradycardia requiring treatment: [Yes / No] — If yes: [Treatment]
• Aspiration: [Suspected / Confirmed / No]
• Esophageal intubation: [Yes / No]
• Airway trauma: [Lips / Teeth / Oropharynx / None]
• Bleeding: [Yes / No] — If yes: source [location], management [intervention]
• Laryngospasm/Bronchospasm: [Yes / No] — If yes: [Management]
• Pneumothorax concern: [Yes / No] — If yes: [Evaluation performed]
• Airway edema: [Yes / No] — If yes: [Management]
• Post-event symptoms: [Sore throat / Hoarseness / Dysphagia / Dental injury / None / Unable to assess due to reason]
• Escalation/Consults: [ENT consult / Imaging / Antibiotics / ICU transfer / None]

Extubation Plan or Ongoing Airway Plan

(Required regardless of current airway status.)

Current status: [Extubated / Continued ETT / Tracheostomy placed / Pre-existing tracheostomy]

If extubated: [Extubation risk assessment; adjuncts used; post-extubation oxygenation plan; monitoring location; specific reintubation plan referencing devices that worked plus backup]

If not extubated or tracheostomy placed: [Indication for continued airway; destination; criteria for later extubation attempt and responsible team; contingency plan for accidental extubation]

Future Airway Recommendations and Alerts

(Required. This section provides critical guidance for future clinicians.)

• What worked—use first next time: [Device, technique, blade, adjuncts, positioning, optimization]
• What failed—avoid next time: [Devices and approaches with reasons]
• Required resources for next airway: [Operator experience level, specific equipment, surgical backup required or not]
• Awake intubation recommended: [Yes / No / Consider] — Rationale: [Reason]
• Mask ventilation: [Easy / Difficult / Impossible] under [conditions] with [adjuncts]
• SAD ventilation: [Easy / Difficult / Impossible] with [device] under [conditions]

Patient Notification Actions:

• Patient or responsible person informed: [Yes / No / Deferred] — If yes: [When and how]; If deferred: [Follow-up plan and responsible service]
• Written notification provided: [Letter / Wallet card / After-visit summary / Not yet provided with plan]
• EMR airway alert or problem list updated: [Yes / No / Pending]
• Communication to primary team or PCP: [Completed / Pending / Not applicable]

Debrief and Quality Review

• Team debrief performed: [Yes / No] (If yes: [One to three key learning points])
• Departmental review criteria met: [Yes / No] — If yes, criteria: [Failed intubation / Emergency invasive airway / Airway-related unplanned admission / Other]; Notification initiated: [Yes / No]

Authentication

Author: [Name, Role]

Date/Time Signed: [Date and time]

Late Entry: [Yes / No] (If yes: [Reason and original event date/time])